A. THANGAMANI RAMALINGAM PT, MSC(PSY), MIAP

psychiatric disorder

A mental disorder or psychiatric disorder is a mental or behavioral pattern or anomaly that causes distress or disability, and which is not developmentally or socially normative.

Mental disorders are generally defined by a combination of how person feels, acts, thinks or perceives.

This may be associated with particular regions or functions of the brain or rest of the nervous system, often in a social context. 

What is Abnormal Behavior?

One definition is that abnormal behavior is any that deviates from central tendencies, like the mean, for example. By this definition, abnormal behavior would be any that is statistically deviant. For example, if most of the population smoked, but you did not, then not smoking would be considered abnormal.

Another similar definition is deviation from socio-cultural norms, not statistical ones. In this definition, abnormality is when one violates behaviors that most consider proper. For example, not shaving, not going to church, and so on, would be abnormal

Other definitions are based on individuals instead of groups. For example, if a person feels uncomfortable in situations where others do not, then that person may be maladjusted

Another possible definition is simply being in trouble: trouble at home, work, school, or with the law

Word normal derived from latin word norma means rule .

Means followed the rule or pattern or standards. When the individual is able to function adquately and performs his daily living activities efficiently and feel satisfied with his life style called as normal behaviour .

NORMAL BEHAVIOUR

The word abnormal with prefix ,’ab’(away from) means away from normal. Abnormality is negative concept it means deviation from norm or standard or rules . Disturbances seen in behaviour which manifests in cognitive domain(thinking, knowing, memory)affective domain (emotion and feeling ) and conative domain (psychomotor activity) individual express his mental distress through thought, feeling and action .

ABNORMAL BEHAVIOUR

Personality types

Operational definition

Characteristics of abnormal behavior

• A perception of reality.• A positive attitude towards one’s

self, acceptance of weakness and pride in strengths.

• Capacity for withstanding anxiety and stress.

• Adequate in work, play and leisure .

• Willingness to use problem solving approches in life process.

• Capacity to adapt oneself to current situation.

• Competence in human relations.

• change in person’s thinking process, memory, perception and judgment.

• Work efficiency will be reduced • Forgetfulness • Unhappiness • Unable to cope • Worried, anxious disturbance in

daily routine activities. • No respect will be given to others or

self. • Lack of gratification. • Lack of self confidence • Feeling of stress

Characteristics of normal behavior

Models of abnormality

Mental and behavioral disorders

The International Classification of Diseases (ICD) is an international standard diagnostic classification for a wide variety of health conditions. Chapter V focuses on "mental and behavioural disorders" and consists of 10 main groups:

F0: ,Sexual including trauma, mental disorders F1: Mental and behavioural disorders due to use of psychoactive substances F2: Schizophrenia, schizotypal and delusional disorders F3: Mood [affective] disorders F4: Neurotic, stress-related and somatoform disorders F5: Behavioural syndromes associated with physiological disturbances and physical

factors F6: Disorders of personality and behaviour in adult persons F7: Mental retardation F8: Disorders of psychological development F9: Behavioural and emotional disorders with onset usually occurring in childhood and

adolescence In addition, a group of "unspecified mental disorders".

The DSM-IV-TR (Text Revision, 2000)

The DSM-IV-TR (Text Revision, 2000) consists of five axes (domains) on which disorder can be assessed. The five axes are:

Axis I: Clinical Disorders (all mental disorders except Personality Disorders and Mental Retardation)

Axis II: Personality Disorders and Mental RetardationAxis III: General Medical Conditions (must be connected to a Mental

Disorder)Axis IV: Psychosocial and Environmental Problems (for example limited

social support network)Axis V: Global Assessment of Functioning (Psychological, social and job-

related functions are evaluated on a continuum between mental health and extreme mental disorder)

Substance abuse disorders

Substance Classes

AlcoholCaffeineCannabisHallucinogens

PCP others

Inhalants

Gambling

OpioidsSedatives, hypnotics, and

anxiolyticsStimulantsTobaccoOther

Characteristics of Various Psychoactive Substances

Substance-Related Disorders

DSM-IV-TR categories of substance-related disorders:Substance-Use Disorders: Those involving

dependence and abuse.Substance-Induced Disorders: Those involving

withdrawal and substance-induced delirium.

Substance-Related Disorders

Substance AbuseExtends over a period of 12 months.Leads to notable impairment or distress.Continues despite social, occupational,

psychological, physical or safety problems.

Substance-Related Disorders

Substance Dependence: Maladaptive pattern of use over 12-month period, characterized by:

Unsuccessful efforts to control use, despite knowledge of harmful effects.

Takes more of substance than intended. Tolerance: Increasing doses are necessary to

achieve desired effect.

Devotes considerable time to activities necessary to obtain the substance.

Substance-Related Disorders

Withdrawal: Distress/impairment in social, occupational, other areas of functioning or physical or emotional symptoms (e.g., shaking, irritability, inability to concentrate) after reducing or ceasing intake.

Intoxication: A substance affecting CNS is ingested and causes maladaptive behaviors or psychological changes.

Substance-Use Disorders

Physical Dependence: State of body such that bodily processes become modified & produce physical withdrawal symptoms when drug is removed.

Psychological Dependence: A compulsion which requires continued use of a drug for some pleasurable effect.

Substance-Induced

IntoxicationWithdrawalPsychotic DisorderBipolar DisorderDepressive Disorder

Anxiety DisorderSleep DisorderDeliriumNeurocognitiveSexual Dysfunction

ALCOHOL- CNS depressantIntoxication

Blood Alcohol Level - 0.08g/dl

Progress from mood lability, impaired judgment, and poor coordination to increasing level of neurologic impairment (severe dysarthria, amnesia, ataxia)

Can be fatal (loss of airway protective reflexes, pulmonary aspiration, profound CNS depression)

Alcohol Withdrawal

Early anxiety, irritability, tremor, HA, insomnia, nausea,

tachycardia, HTN, hyperthermia, hyperactive reflexes Seizures

generally seen 24-48 hours most often Grand mal

Withdrawal Delirium (DTs) generally between 48-72 hours altered mental status, hallucinations, marked autonomic

instability life-threatening

scale

CIWA (Clinical Institute Withdrawal Assessment for Alcohol)

Assigns numerical values to orientation, Nausea/Vomiting, tremor, sweating, anxiety, agitation, tactile/ auditory/ visual disturbances and Headache. Vital Signs checked but not recorded.

Total score of > 10 indicates more severe withdrawal

Alcohol Withdrawal (cont.)

Benzodiazepines GABA agonist - cross-tolerant with alcohol reduce risk of SZ; provide comfort/sedation

Anticonvulsants reduce risk of SZ and may reduce kindling helpful for protracted withdrawal Carbamazepine or Valproic acid

Thiamine supplementation Risk thiamine deficiency (Wernicke/Korsakoff)

Alcohol treatment

Support education skills training psychiatric and psychological treatment

Medications:Disulfiram NaltrexoneAcamprosate

Benzodiazepine( BZD)/ Barbiturates

Benzodiazepine( BZD)/ Barbiturates

Intoxication similar to alcohol but less cognitive/motor impairment variable rate of absorption (lipophilia) and onset of

action and duration in CNS the more lipophilic and shorter the duration of action,

the more "addicting" they can be

Benzodiazepine

Withdrawal Similar to alcohol with anxiety, irritability, insomnia, fatigue, HA, tremor,

sweating, poor concentration - time frame depends on half life Common detox mistake is tapering too fast; symptoms worse at end of

taper Convert short elimination BZD to longer elimination half life drug and then

slowly taper Outpatient taper- decrease dose every 1-2 weeks and not more than 5 mg

Diazepam dose equivalent 5 diazepam = 0.5 alprazolam = 25 chlordiazepoxide = 0.25 clonazepam = 1 lorazepam

May consider carbamazepine or valproic acid especially if doing rapid taper

Benzodiazapines

Alprazolam (Xanax) t 1/2 6-20 hrs*Oxazepam (Serax) t 1/2 8-12 hrs*Temazepam (Restoril) t 1/2 8-20 hrsClonazepam (Klonopin) t 1/2 18-50 hrs*Lorazepam (Ativan) t1/2 10-20 hrsChlordiazepoxide (Librium) t1/2 30-100 hrs (less lipophilic)Diazepam (Valium) t ½ 30-100 hrs (more lipophilic)

*Oxazepam, Temazepam & Lorazepam- metabolized through only glucuronidation in liver and not affected by age/ hepatic insufficiency.

Opioids

OPIOIDSBind to the mu receptors in the CNS to modulate

pain

Intoxication- pinpoint pupils, sedation, constipation, bradycardia, hypotension and decreased respiratory rate

Withdrawal- not life threatening unless severe medical illness but extremely uncomfortable. s/s dilated pupils lacrimation, goosebumps, n/v, diarrhea, myalgias, arthralgias, dysphoria or agitation

Rx- symptomatically with antiemetic, antacid, antidiarrheal, muscle relaxant (methocarbamol), NSAIDS, clonidine and maybe BZD

Neuroadaptation: increased DA and decreased NE

Treatment - Opiate Use Disorder

CD treatment support, education, skills building, psychiatric and psychological

treatment,

Medications Methadone (opioid substitution) Naltrexone Buprenorphine (opioid substitution)

Treatment - Opiate Use Disorder

Naltrexone Opioid blocker, mu antagonist 50mg po daily

Methadone Mu agonist Start at 20-40mg and titrate up until not craving or using illicit opioids Average dose 80-100mg daily Needs to be enrolled in a certified opiate substitution program

Buprenorphine Partial mu partial agonist with a ceiling effect Any physician can Rx after taking certified ASAM course Helpful for highly motivated people who do not need high doses

Stimulants

STIMULANTS

Intoxication (acute) psychological and physical signs

euphoria, enhanced vigor, gregariousness, hyperactivity, restlessness, interpersonal sensitivity, anxiety, tension, anger, impaired judgment, paranoia

tachycardia, papillary dilation, HTN, N/V, diaphoresis, chills, weight loss, chest pain, cardiac arrhythmias, confusion, seizures, coma

Chronic intoxication affective blunting, fatigue, sadness, social withdrawal, hypotension,

bradycardia, muscle weaknessWithdrawal

not severe but have exhaustion with sleep (crash) treat with rest and support

Cocaine

Route: nasal, IV or smoked Has vasoconstrictive effects that may

outlast use and increase risk for CVA and MI (obtain EKG)

Can get rhabdomyolsis with compartment syndrome from hypermetabolic state

Can see psychosis associated with intoxication that resolves

Neuroadaptation: cocaine mainly prevents reuptake of DA

Treatment - Stimulant Use Disorder (cocaine)

CD treatment including support, education, skills, CA

Pharmacotherapy No medications FDA-approved for treatment If medication used, also need a psychosocial treatment component

AmphetaminesSimilar intoxication syndrome to cocaine

but usually longerRoute - oral, IV, nasally, smoked No vasoconstrictive effectChronic use results in neurotoxicity

possibly from glutamate and axonal degeneration

Can see permanent amphetamine psychosis with continued use

Treatment similar as for cocaine but no known substances to reduce cravings

Neuroadaptation inhibit reuptake of DA, NE, SE - greatest effect on DA

Treatment – Stimulant Use Disorder (amphetamine)

CD treatment: including support, education, skills, CA

No specific medications have been found helpful in treatment although some early promising research using atypical antipsychotics (methamphetamine)

Tobacco

Drug Interactions induces CYP1A2 - watch for interactions when start or stop

(ex. Olanzapine)No intoxication diagnosis

initial use associated with dizziness, HA, nauseaNeuroadaptation

nicotine acetylcholine receptors on DA neurons in ventral tegmental area release DA in nucleus accumbens

Tolerance rapid

Withdrawal dysphoria, irritability, anxiety, decreased concentration,

insomnia, increased appetite

Treatment – Tobacco Use Disorder

Cognitive Behavioral TherapyAgonist substitution therapy

nicotine gum or lozenge, transdermal patch, nasal spray Medication

bupropion (Zyban) 150mg po bid, varenicline (Chantix) 1mg po bid

Hallucinogens

Hallucinogens

Naturally occurring - Peyote cactus (mescaline); magic mushroom(Psilocybin) - oral

Synthetic agents – LSD (lysergic acid diethyamide) - oral

DMT (dimethyltryptamine) - smoked, snuffed, IV

STP (2,5-dimethoxy-4-methylamphetamine) –oral

MDMA (3,4-methyl-enedioxymethamphetamine) ecstasy – oral

MDMA (XTC or Ecstacy)

Designer club drugEnhanced empathy, personal insight,

euphoria, increased energy 3-6 hour durationIntoxication- illusions, hyperacusis,

sensitivity of touch, taste/ smell altered, "oneness with the world", tearfulness, euphoria, panic, paranoia, impairment judgment

Tolerance develops quickly and unpleasant side effects with continued use (teeth grinding) so dependence less likely

MDMA (XTC or Ecstacy)Neuroadaptation- affects serotonin (5HT), DA, NE but

predominantly 5HT2 receptor agonistsPsychosis

Hallucinations generally mild Paranoid psychosis associated with chronic use Serotonin neural injury associated with panic, anxiety,

depression, flashbacks, psychosis, cognitive changes.Withdrawal – unclear syndrome (maybe similar to

mild stimulants-sleepiness and depression due to 5HT depletion)

Cannabis

Cannabis

Most commonly used illicit drug in America THC levels reach peak 10-30 min, lipid soluble; long half life

of 50 hours Intoxication-

Appetite and thirst increase Colors/ sounds/ tastes are clearer

Increased confidence and euphoriaRelaxationIncreased libidoTransient depression, anxiety, paranoiaTachycardia, dry mouth, conjunctival injectionSlowed reaction time/ motor speedImpaired cognitionPsychosis

Neuroadaptation CB1, CB2 cannabinoid receptors in brain/ body Coupled with G proteins and adenylate cyclase to CA channel

inhibiting calcium influx Neuromodulator effect; decrease uptake of GABA and DA

Withdrawal - insomnia, irritability, anxiety, poor appetite, depression, physical discomfort

Treatment-Detox and rehab

- Behavioral model-No pharmacological treatment but may treat other psychiatric symptoms

PCP

PHENACYCLIDINE ( PCP)"Angel Dust"

Dissociative anestheticSimilar to Ketamine used in anesthesiaIntoxication: severe dissociative reactions –

paranoid delusions, hallucinations, can become very agitated/ violent with decreased awareness of pain.

Cerebellar symptoms - ataxia, dysarthria, nystagmus (vertical and horizontal)

With severe OD - mute, catatonic, muscle rigidity, HTN, hyperthermia, rhabdomyolsis, seizures, coma and death

Treatment antipsychotic drugs or BZD if required Low stimulation environment acidify urine if severe toxicity/coma

Neuroadaptation opiate receptor effects allosteric modulator of glutamate NMDA

receptor

No tolerance or withdrawal

ANXIETY DISORDERS

ANXIETY DISORDERS

Etiology – Biopsychosocial perspective

• emotion

• biology

• environment

• behaviour

• cognition

ANXIETY DISORDERS

Types – Specific phobia

• animal

• environmental

• blood, injury, injection

• specific situation – elevators, flying

• other

ANXIETY DISORDERS

Types – Specific phobia – Diagnostic features

• marked and persistent fear and avoidance of specific stimulus or situation

• must interfere significantly with person’s life

• must be considered excessive or unrealistic

• ANS arousal

ANXIETY DISORDERS

Types – Specific phobia

• prevalence rates from 7-11%

• often emerge during adolescence, usually earlier than age 25

• tend to be chronic, but may fluctuate over life course

• usually assessed with self-report

• conditioning theories systematic desensitization

ANXIETY DISORDERS

Systematic desensitization (SD) for specific phobia

Wolpe (1958) – reciprocal inhibition and SD

3 components of SD

• construction of stimulus hierarchy

• progressive (deep muscle) relaxation training

• progress through the hierarchy while practicing relaxation response

ANXIETY DISORDERS

Panic disorder

• recurrent, unexpected panic attacks

• persistent concern, preoccupation with having another attack

• worry about consequences of attack

• significant behaviour change in response to attacks

ANXIETY DISORDERS

Panic disorder – Other clinical features

• often accompanied by avoidance behaviours (agoraphobia)

• possible to have agoraphobia without panic attacks

• onset around late adolescence, early adulthood

• more women than men

• high rates of service utilization, poor quality of life

ANXIETY DISORDERS

Clark’s cognitive model of panic disorder)

• catastrophic misinterpretation of arousal-related bodily sensations

• agoraphobia (avoidance) as way of coping

ANXIETY DISORDERS

Obsessive-compulsive disorder (OCD)

• recurrent obsessions, compulsion, or both

• obsessesions – thoughts, images, impulses, that are persistent, markedly distressing

• compulsion – repetitive behaviours performed in response to an obsession

• common obsessions – violence, sex, contamination, order

• common compulsions – washing, cleaning, checking, seeking reassurance, ordering or arranging objects

• cleaners vs. checkers – focus on harm vs. order

ANXIETY DISORDERS

Obsessive-compulsive disorder (OCD) - Background

• very rare – 2.5% lifetime prevalence rate

• little gender difference

• high overlap with depression and Tourette’s syndrome

ANXIETY DISORDERS

Obsessive-compulsive disorder (OCD) – Psychodynamic perspective

• anal fixation – “Does anal-retentive have a hyphen?”

• reaction formation, undoing, displacement

ANXIETY DISORDERS

Obsessive-compulsive disorder (OCD) –Treatments

• Prozac - SSRIs

• Exposure and response prevention

ANXIETY DISORDERS

Post-traumatic stress disorder (PTSD)

Person has been exposed to traumatic event

3 symptom clusters

• recurrent re-experiencing of event

• avoidance of trauma-related stimuli and numbing

• increased arousal

Persists for at least 1 month after trauma

ANXIETY DISORDERS

Post-traumatic stress disorder (PTSD) –Etiology

Cognitive theories

• expectations and appraisals

• fear structure in long-term memory

• fear conditioning

ANXIETY DISORDERS

Generalized anxiety disorder (GAD) • Core feature is worrying – worries are unrealistic, difficult to control, excessive

• “Free floating” anxiety

• Verbal thoughts rather than images as in OCD

• Motor tension, vigilance, scanning

• “What if?” – background of intolerance of uncertainty

ANXIETY DISORDERS

Generalized anxiety disorder (GAD) –Description3 key features

• uncontrollability

• intolerance of uncertainty

• ineffective problem-solving skills

ANXIETY DISORDERS

Treatments - Pharmacotherapy

3 main drugs

• Xanax

• Paxil

• Zoloft

SSRIs, bezodiazepines, tricyclic anti-depressants, MAOs

ANXIETY DISORDERS

Treatments - Exposure

• flooding, response prevention

• confrontation with anxiety-producing stimulus

• developing more adaptive internal representations of the stimuli and their non-threatening consequences

ANXIETY DISORDERS

Treatments – Cognitive restructuring

• identify maladaptive cognitions

• challenge maladaptive cognitions

• develop more adaptive cognitions

ANXIETY DISORDERS

Treatments – Relaxation training

• Decreases physiological arousal through

• Deep muscle relaxation

• Positive imagery

• Meditation

• Deep breathing

Sleep disorders

ICSD summary

1990, 1997

(WHM p. 202)

Dyssomnias

A broad category of sleep disorders characterized by either hypersomnia or insomnia.

The three major subcategories include intrinsic (i.e., arising from within the body), extrinsic (secondary to environmental conditions or various pathologic conditions), and disturbances of circadian rhythm.

Insomnia is often a symptom of a mood disorder (i.e., emotional stress, anxiety, depression) or underlying health condition (i.e., asthma, diabetes, heart disease, pregnancy or neurological conditions).[7]

Primary hypersomnia. Idiopathic hypersomnia: a chronic neurological disease similar to narcolepsy in which there

is an increased amount of fatigue and sleep during the day. Recurrent hypersomnia - including Kleine–Levin syndromePosttraumatic hypersomniaMenstrual-related hypersomniaSleep disordered breathing (SDB), including (non exhaustive):Several types of Sleep apneaSnoringUpper airway resistance syndromeRestless leg syndromePeriodic limb movement disorderCircadian rhythm sleep disordersDelayed sleep phase disorderAdvanced sleep phase disorderNon-24-hour sleep–wake disorder

Parasomnia

REM sleep behaviour disorder Sleep terror . Sleepwalking (or somnambulism) Bruxism (Tooth-grinding) Bedwetting or sleep enuresis. Sleep talking (or somniloquy) Sleep sex (or sexsomnia) Exploding head syndrome - Waking up in the night hearing

loud noises

Medical or psychiatric conditions that may produce sleep disorders

Psychosis (such as Schizophrenia)Mood disordersDepressionAnxietyPanicAlcoholismSleeping sickness - a parasitic disease

which can be transmitted by the Tsetse fly

“Bad Dreams”PTSD: Traumatic experience that is re-experienced in

the dream. Any sleep stage. Very terrifying, worse than nightmares. Daytime symptoms also.

Anxiety Dreams: REM, “bad regular dream”Nightmares: REM, intense emotion, awaken with

full alertness / terrified / emotional++ / SNS active. Night Terrors: NREM early in night, mainly kids.

Scream++, inconsolable, thrashing, dazed, SNS+++, no recall in morning. Benign.

Sleepwalking vs. RBDSleepwalking:

NREM sleep, first 1/3 of night, children and teens; may persist to adulthood. Not a dream. Confused if awoken. Simple to very complex behaviour. Rarely violent.

Sleep Talking: Children; NREM; rarely intelligible; often sleepwalk too. Can

persist to adulthood.REM Behaviour Disorder:

Old men; brainstem stroke or degeneration; loss of normal REM paralysis nuclei; frequently severe injuries; mostly last 1/3 of night.

NARCOLEPSY

A chronic neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. People with narcolepsy often experience disturbed nocturnal sleep and an abnormal daytime sleep pattern, which often is confused with insomnia. Narcoleptics, when falling asleep, generally experience the REM stage of sleep within 5 minutes, while most people do not experience REM sleep until an hour or so later.

Periodic Limb Movement Dis.

Due to low brain iron stores, esp. in basal ganglia. Low ferritin, B12, folate -- these are needed to make dopamine.

Electrodes on anterior tibialis musc. (shins)RLS = leg cramps / movements in evening,

before bed. PLMD = same, but in sleep. Day symptoms similar to UARS – result of

sleep fragmentation, loss of stages 3 & 4.

PLMD, cont’d

Worsened by: caffeine, red wine, spices, SSRI antidepressants

Helped by: exercise, warm baths, opiates, stretching, massage, some sleeping pills

Medical Treatment: dopamine agonists (ropinirole, pramipexole), or dopamine “feedstock” L-DOPA.

REM Behaviour Disorder

Older men, esp. those with Parkinson’s, or Lewy Body dementia

Brainstem damage: n. magnocellularis, n. paramedianus (REM paralytic pathways)

Severe brain injuriesUsually no daytime psychopathologyThis is how the general public conceives of

“sleepwalking” (incorrect: it’s in NREM).

RBD, Treatment

Antidepressants are almost all REM suppressants, but they worsen RBD (not known why).

Clonazepam (anti-epileptic BZD) is the treatment of choice.

RBD can be seen in alcohol withdrawal and various drug abuse withdrawal.

Insomnia

A broad term denoting unsatisfactory sleepPerception that sleep is inadequate or

abnormalCommon problemA symptom, not a disease or sign, therefore

difficult to measure

Diagnosis

Complaint if sleep is: Brief or inadequate Light or easily disrupted Non-refreshing or non-restorative

International Congress of Sleep Disorders Classification

Transient or acute Few days to 2-4 weeks

Chronic Persisting for more than 1-3 months

Definitions

Mild Almost nightly complaint of non-restorative sleep Associated with little or no impairment of social or

occupational functioningModerate

Nightly complaints of disturbed sleep Mild to moderate impairment of social or occupational

functionSevere

Nightly complaints of disturbed sleep Severe daytime dysfunction

Classification

Sleep initiating insomniaSleep maintaining insomniaEarly morning insomnia

Short period of sleepNon-restorative sleep

Multiple awakenings Combination of above patterns

Presentation Goals

Review of normal sleep cycleCauses of insomniaDiagnosis and assessment of insomniaTreatment modalities

Stages of Sleep

Non-Rapid Eye Movement (NREM) sleep Stage I Stage II

Stages I & II are light sleep Stage III Stage IV

Stages III & IV are deep sleep

Rapid Eye Movement (REM) sleep

Normal Sleep Pattern

Sleep is an integral portion of human existence which is sensitive to most physiological or pathological changes (aging, stress, illness, etc.)

Why do we sleep? Not clear, but has to do with regeneration (NREM) and brain

development/memory (REM) – REM sleep is essential for the development of the mammalian brain

Stages III & IV are involved in synaptic “pruning and tuning”

Normal Sleep Values

Normal sleep per day is between 6-8 hours, although some people can maintain a 4-6 hour cycle

4-6 NREM/REM cycles per nightSleep structure changes throughout lifeWakefulness after sleep

Less than 30 minutesSleep Onset Latency (SOL)

Less than 30 minutesREM Sleep Latency

70-120 minutes

Epidemiology

Studies throughout the world show that it occurs everywhere

Depending on the area, study, etc., between 10-50% of the population are affected

Increases with ageTwice as common in females

Up to the age of 30, there is little difference between sexes Beyond 30 years, it is more common in females Beyond 70 years, females are affected twice as much as males

3 P’s of Acute Insomnia

Predisposition Anxiety, depression, etc.

Precipitation Sudden change in life

Perpetuation Poor sleep hygiene

Precipitating causes lower the threshold for acute insomnia in people with predisposing and perpetuating causes as well as further lowers the threshold for chronic insomnia

Start aggressive treatment in the ACUTE phase, before the patient goes into CHRONIC insomnia

Acute Insomnia

Adjustment sleep disorder Acute stress such as momentous life events or unfamiliar

sleep environments PSG: increased SOL(sleep onset latency“)increased

awakenings and sleep fragmentation with poor sleep efficiency

More common in women and those with anxietyJet Lag-desynchronosis-chronobiological 

Symptoms last longer with eastbound travel Remits spontaneously in 2-3 days More common in the elderly

Chronic Insomnia

Primary or Intrinsic Secondary or ExtrinsicCauses

Changes in circadian rhythm, behavior, environment Body movements in sleep Medical, neurological, psychiatric disorders Drugs

Primary/Intrinsic Insomnia

Idiopathic Starts early in childhood, rare but relentless course Rare disorders affect both genders CNS abnormalities, unknown etiology, etc.

Sleep State Misinterpretation (5%) Underestimate of the sleep obtained Females affected more than males

Psycho physiological insomnia (30%) Maladaptive sleep-preventing behaviors develop and progress

to become dominant factors Females more than males

Secondary/Extrinsic Insomnia

1. Circadian rhythm sleep disorder: sleep attempted at a time when the circadian clock is promoting wakefulness Advanced sleep phase syndrome Delayed sleep phase syndrome Irregular sleep/wake patterns Non-24 hour sleep/wake syndrome Shift work sleep disorder Short sleeper

2. Behavioral disorders: rooted behaviors that are arousing and not conductive to sleep

Inadequate sleep Limit setting sleep disorder Nocturnal eating/drinking syndrome Sleep onset association disorder

3. Environmental factors Environmental sleep disorder Food allergy insomnia Toxin-induced sleep disorder

4. Movement disorders PLMS disorder (5%) RLS syndrome (12%) REM behavior disorder

5. Medical Disorders: Respiratory Altitude insomnia Central alveolar hypoventilation syndrome Central apnea syndrome COPD OSAS (4-6%) obstructive sleep apnea Sleep-related asthma

6. Medical: Cardiac Nocturnal myocardial ischemia

7. Medical: GI Peptic ulcer disease GERD

8. Medical: Musculoskeletal Fibromyalgia Arthritis

9. Medical: Endocrine Hyperthyroidism Cushing’s disease Menstrual cycle association Pregnancy

10. Medical: Neurological Cerebral degeneration disorder Dementia Fatal familial insomnia Parkinson’s disease Sleep related epilepsy Sleep related headaches

11. Medical: Psychiatric Alcoholism Anxiety disorders Mood disorders Panic disorders Psychosis Drug dependency

12. Pharmacological causes Alcohol dependent sleep disorder Hypnotic dependent sleep disorder Stimulus dependent sleep disorder Medications

B-blockers Theophylline L-dopa

Parasomnia Events

Physical phenomena occurring in sleep Confusional arousals Nightmares Nocturnal leg cramps Nocturnal paroxysmal

dystonia REM sleep behavior disorder

Rhythmic movement disorder

Painful erections Sleep starts Sleep terrors Sleep walking Abnormal swallowing Hyperhidrosis Laryngospasms

Physical, Emotional, and Cognitive Effects of Insomnia

Mood changes, irritability, poor concentration, memory defects, etc.

Impairs creative thinking, verbal processing, problem solvingRisk of errors, accidents due to excessive daytime sleepiness

Markedly increases if awake more than 16-18 hours (micro-sleep attacks)Increased appetite, decreased body temperaturePhysiologic effects

Rats die after 11-12 days of sleep deprivation Hippocampal atrophy in chronic jet lag or shift work

Evaluation

HISTORY! Precipitating factors Psychiatric and medical disturbances Medications Sleep hygiene Circadian tendencies Cognitive distortions and conditional arousals

Sleep diary

Evaluation

PSG(Polysomnography)if PLMS or sleep-related breathing disorder

or if CBT, sleep hygiene, pharmacological interventions fail as recommended by the AASM Not routinely employed in the evaluation of transient

or chronic insomnia Should not be substituted for a careful clinical history

Epworth Sleepiness Scale

A good measure of excessive daytime sleepiness. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would affect you. Use the following scale to choose the most appropriate number for each situation:

0=no chance of dozing 1=slight chance 2=moderate chance 3=high chance

Sitting and reading ____ Watching TV ____ Sitting inactive in a public place (ex. theater, meeting) ____ As a passenger in a car for an hour without a break ____ Lying down to rest in the afternoon ____ Sitting and talking to someone ____ In a car, while stopped for a few minutes in traffic ____ ____ Total Score Normal < 10 Severe > 15

Insomnia questionnaire

I have real difficulty falling asleep. Thoughts race through my mind and this prevents me from

sleeping. I wake during the night and can’t go back to sleep. I wake up earlier in the morning than I would like to. I’ll lie awake for half an hour or more before I fall asleep. I anticipate a problem with sleep almost every night

If you checked three or more boxes, you show symptoms of insomnia, a persistent inability to fall asleep or stay asleep.

Treatment Selection

1. Meet and educate about disease, goals, options, side effects, and document safety.

2. Identify the 3 P’s.3. Intrinsic v. Extrinsic4. Treat perpetuating causes

Sleep hygiene, progressive muscle relaxation, biofeedback, stimulus control, sleep restriction, cognitive behavior therapy (CBT), combination of medications and CBT

CBT

Longest lasting improvements, assuming the precipitating cause is dealt with

“counseling” or “talk through” therapy for thoughts and attitudes that may be leading to the sleep disturbances

Identifying distorted attitudes or thinking that makes the patient anxious or stressed and replacing with more realistic or rational ones

CBT Examples

“I need more hours of sleep or I will not function”

“I can never die”Uses restructuring techniquesShort circuit cycle of insomnia, cognitive

distortions, distressSleep hygiene, relaxation, stimulus control,

sleep restrictions

Sleep Hygiene

Exercise earlier during the day, and no more than 4-6 hours before sleep

Keep bedroom dark and quiet, to be used only for sex or sleep

Curtail time in bed to only when sleepyFixed sleep/wake times for 365 daysAvoid napsAvoid stimulus or stimulating activities before sleep

or in bedNo alcohol at least 4 hours before sleep, no

caffeine after noon, and quit smoking!!Light snack before bedtime

Stimulus Control

Use bedroom for sleep or sex onlyGo to bed only when tired and sleepyRemove clock from the bedroom to avoid

constantly watching itRegular sleep/wake timesLight therapy if requiredNo bright lights when you wake up at night

Sleep Restriction

An effective form of treatmentEstimate the time actually asleep then limit

bedtime to that amount, but no less than 5 hours

Add time in bed gradually once the patient sleeps more than 85% of that time

Pharmacotherapy

Nationally, there has been a decline in hypnotic usage with an increase in usage of non-hypnotics Trazadone Seroquel

Self-medication with alcohol and over-the-counter medications Benadryl Nyquil

Benzodiazepines  Dose Half-life Comments

Flurazepam(Dalmane)

15,30 mg Long Daytime drowsiness common; rarely used

Clonazepam(Klonopin)

0.5-2 mg Long Used for PLM, REM behavior disorder; can cause morning drowsiness

Temazepam (Restoril)

15,30 mg Intermediate  

Estazolam (ProSom)

1-2 mg Intermediate Can cause agranulocytosis

Triazolam (Halcion)

0.125,0.25 mg Short Rebound insomnia may occur

Zolpidem (Ambien)

5,10 mg Short A nonbenzodiazepamZopliclone

(Sonata)5,10 mg Short , 1-1.5 hours  

 

 

 

A nonbenzodiazepam

Recent Medication Additions

Eszopiclone 1,2,3 mg Intermediate • Approved for chronic insomnia

(Lunesta) Action 6-8 hrs.Zolpidem 10 mg Action same as above(Amvien CR)Rozerem(Ramelton)

Alternative Medications

Antidepressants Not much research Some, including SSRIs, can cause daytime drowsiness

Melatonin Good for jet leg, especially in elderly, but not much information on

long-term use Reported to cause depression, vasoconstriction

Benadryl Rarely indicated, can cause a hangover

Herbal supplements Use in conjunction with a sleep log

Conclusion

Insomnia is a complex symptom with many causes and perpetuating influences

It is nerve-racking for patients and physicians yet it is very remediable, if properly diagnosed and treated

It should be aggressively treated as emerging evidence is that chronic insomnia can precipitate major depressive disorder Depression in turn confers an increased risk of suicide,

cardiovascular disease, death, etc.